Healthcare Provider Details

I. General information

NPI: 1720701675
Provider Name (Legal Business Name): TYISHA THOMAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 C ST STE B
LEMOORE CA
93245-2931
US

IV. Provider business mailing address

PO BOX 757
LEMOORE CA
93245-0757
US

V. Phone/Fax

Practice location:
  • Phone: 559-871-1780
  • Fax:
Mailing address:
  • Phone: 559-871-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number77145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: